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Abstract
Background: rural and community hospitals play a structuring role in ensuring healthcare access for geographically dispersed populations, yet they face chronic financial fragility stemming from low patient volumes, unfavorable payer mix, dependence on non-operating revenue, and technological lag. Objective: to systematize and critically analyze the national and international scientific literature published between 2021 and 2026 on hospital financial sustainability, articulating it with four related axes — governance, Revenue Cycle Management (RCM), leadership, and operational efficiency — through the lens of integrated health management. Methods: an integrative literature review, with search and screening steps inspired by PRISMA, conducted by a single author with the support of academic search engines and indexed databases (PubMed/MEDLINE, Scopus, Web of Science, SciELO, BVS/LILACS, PLOS, Frontiers, and institutional grey literature). Seventy-eight unique records were screened, 38 full texts assessed, and 32 studies and documents included in the final synthesis, subjected to a simplified methodological quality appraisal inspired by the AMSTAR-2 and MMAT instruments. Results: the studies reviewed reveal a cyclical, cumulative pattern of financial vulnerability in small hospitals, in which governance deficiencies, the absence of structured revenue-cycle management, leadership gaps and low operational efficiency reinforce one another. A relevant asymmetry was identified between the bodies of literature reviewed: the financial-sustainability axis is dominated by U.S. studies, whereas the leadership axis is dominated by lower-impact Brazilian literature — a limitation explicitly discussed. Conclusion: as a theoretical contribution of the author, an integrated management model is proposed, combining participatory governance, professionalized revenue-cycle management, leadership development, and indicator-driven operational efficiency, underpinned by stable public financing policies — a proposal that still requires direct empirical testing.
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